MJHS Phone:  615.758.5606
MJHS Fax:   615-758-5645

 

 

RELEASE OF INFORMATION

 

I do hereby authorize Wilson County Schools to disclose and receive medical and academic information to this student’s parents, relevant school personnel, and medical doctors/health care professionals who are directly involved in making educational decisions and programming plans.  It is also granted that relevant medical information be disclosed within educational reports and records. 

 

____________________________________               _______________________­­­­­­­______­­­

Student’s Name                                                                               Birth Date

 

___________________________________________                   _____________________­­­­_____________

School                                                                                              Name of Contact Person

 

___________________________________________                  __________________________________

Student Signature                                                  Date                  Parent /Guardian Signature                 Date

 

(Signature required of student 18 years or older unless

parents have been granted Power of Attorney[1])

 

This section to be completed only if information is being requested or sent to an outside agency.

 

SPECIFIC INFORMATION REQUESTED TO/FROM OUTSIDE AGENCY: ___________________________

                                                                                                                                                                  (Outside Agency)

  Current IEP

  Psychological Evaluation(s)

  Speech/Language Evaluation(s)

  Medical Information

  ADD/ADHD Evaluation Summary

  Other:  _____________________________________________________________________________

 

Please send these records to the attention of __________________________________________________.

 

Thank you,

 

 

 

Wilson County Schools


[1] Power of Attorney Must be Attached